Live webchat with David Bogod, president-elect of the Obstetric Anaesthetists Association, Thurs 3 March, 8-9pm

[GeraldineMumsnet]

Following the discussion about epidurals on this thread, David Bogod got in touch because he'd read the thread after seeing it mentioned in the Sunday Times. We're very pleased to welcome him to Mumsnet for a webchat.

David is consultant obstetric anaesthetist at City Hospital, Nottingham, where he's worked for 21 years and carried out more than 2,000 epidural procedures. His unit has around 5,700 deliveries a year, with an epidural rate of around 25%.

He's also president-elect of the Obstetric Anaesthetists Association and vice-pres of the Association of Anaesthetists of Great Britain and Ireland.

David has two grown-up boys (one delivered by forceps, one spontaneous delivery, both under epidural).

If you've got any questions to put to David about the scientific, political or social aspects of epidural pain relief in labour, or any other issues relating to childbirth, then please come and join him on Thursday evening. Failing that, please post your question here as usual.

[DavidBogod]

Thanks expat. I'll check out the availability of epidural analgesia in Scotland and get back to you. I imagine that it must be fairly patchy outside the cities and big towns.

@expatinscotland

Thank you for coming, Mr Bogod.

I was one of the more vociferous posters on the original thread so am interested in your comments.

I had two births under epidural - one back to back labour with a baby who also turned out to have her hand up cupping her ear. I waited 4 hours for an epidural in that case. Ended in delivery by H-F forceps with no negative effect.

Another birth, like doricpatter, it was a case of transferring to a CLU (Paisley) to get one. This was a 1.5 hour ambulance journey, they knew I was coming and why I was transferring, yet I still waited hours again for an epidural, repeating my request (the reason why I came there to give birth, anyway) for hours as I was left alone (no birth partner, either). Had diamorphine. It just made me stoned.

My son was over 2lbs. heavier than either of his sisters, had cord was wrapped round his neck and was delivered by ventouse - no episiotomy, although I did sustain a 2nd degree tear which healed well.

My concern is that, as more and more hospitals are closed, this will be a more common scenario.

Basically, particularly in Scotland, the option to have epidural pain relief is becoming less and less of an option at all.

[DavidBogod]

Well, this one's down to you guys. However, I do understand that Mumsnet has links with the RCM Heads of Midwifery Advisory Group, so that might be a good place to start.

As I understand it, Mumsnet can be a very powerful lobbying group

@Ushy

Hello David, thanks for coming You suggst that women have a conversation at national level with midwives but HOW? The charities that the government listens to are ALL natural childbirth ones and their views are exactly the same as midwives.

[DavidBogod]

@strandednomore

This may be a really basic question but can you outline the reasons why someone may be refused an epidural?

Strandednomore. There are some medical reasons why an epidural might be regarded as unsafe but these are rare. Significant infection in the blood stream or at the site of epidural puncture; abnormal blood clotting; major back surgery; some heart conditions. Epidurals are a reasonable option for the vast majority of labouring women.

[RachelMumsnet]

We're having a few issues with the quote facility at the moment which we're trying to rectify. Please bear with us...

[expatinscotland]

Thanks for that.

The first time, I was in a big city (Edinburgh)/ERI. Still had to beg and beg and insist on VE's as was told I could not have one before I was 4cm dilated.

Second time, I was at Paisley/RAH. Glasgow, basically.

Again, had to keep repeating and repeating.

When I posted that I got instant pain relief from the epidural I received there, a midwife on here posted that I must not have been in that much pain then .

[DavidBogod]

@ohmeohmy

why do we have a culture of viewing gas and air as not a powerful anaesthetic in childbirth? People see it as 'just G&A' as though it won't affect the baby like other drugs.

ohmeohmy. The active drug in gas and air is nitrous oxide ('laughing gas'), delivered 50:50 with oxygen. Gas and air is really pretty benign. It provides mild pain relief with some sedation and, because it is self-administered, it is really very safe indeed. Studies show no measurable effect on the baby at all.

[OompaLumpa]

Dear Mr Bogod, i am expecting my first child in June. I have been advised by my consultant that due to my medical history (severe asthma with a couple of ventilations) that i should either have a c-section or at the very least an "early" epidural to help me.
I am worried that on the day these options might not actually be available to me due to resourcing. Do you have any hints or tips on how to make sure i get the care i am told i need?
Many thanks.

[expatinscotland]

For plenty of us, G&A did nothing for pain relief.

[rempy]

To add anecdote to Dr Bogods snap stats, I am currently working in a 6500 delivery a year unit as the dedicated anaesthetist. Converse to his experience I have never been told I can't put an epidural in because of midwifery staffing issues. I do however frequently have to say that I will be along in a half to one hour because I'm in theatre with a patient either for caesarean section, or repair following delivery.

Which is an interesting disparity.

[DavidBogod]

@OompaLumpa

Dear Mr Bogod, i am expecting my first child in June. I have been advised by my consultant that due to my medical history (severe asthma with a couple of ventilations) that i should either have a c-section or at the very least an "early" epidural to help me.
I am worried that on the day these options might not actually be available to me due to resourcing. Do you have any hints or tips on how to make sure i get the care i am told i need?
Many thanks.

You need to make sure you see an anaesthetist in the antenatal period. The advice you've been given sounds very sensible, although most asthma improves during pregnancy as long as you keep taking your medication. I am quite certain that, having flagged you up in this way, you will receive all the help you need. We always prioritise those patients who have a medical indication for an epidural.

Good luck!

[DavidBogod]

@apple0211

I would like to know at what point is it 'too late' for an epidural - at 5 cms dilated I was told it was to late for me to have an epidural, it was only when I assertively challenged this that was I able to have an epidural.

apple0211. Once an anaesthetist is in attendance, you have to expect to wait at least 30 minutes to elapse before the pain goes away. There is therefore - and understandably - a reluctance to start the epidural procedure when birth is regarded as imminent. I have often stopped half-way through doing an epidural to help deliver the baby! However, predictions regarding the expected time of delivery are notoriously inaccurate, so the default position should be to proceed to an epidural unless 10 cm dilated and actively pushing. We often insert epidurals at full dilatation during the early part of the second stage before pushing starts. Some midwives do have a tendency to try to artificially limit the range of cervical dilatation over which an epidural can be done (as an extreme example, some might say that before 4 cm you're not in active labour and after 7 cm you're in transition). This is not evidence-based, and goes against NICE guidelines.

[Antidote]

My question is just out of curiosity-

My epidural was topped up prior to having an emergency section, and I got really bad shivering and chattering teeth as if I was freezing cold. I think that the lovely anaesthetist told me it was normal, and may have explained why but I can't remember! Do lots of people experience this, and if so why?

Thank you.

[DavidBogod]

@Antidote

My question is just out of curiosity-

My epidural was topped up prior to having an emergency section, and I got really bad shivering and chattering teeth as if I was freezing cold. I think that the lovely anaesthetist told me it was normal, and may have explained why but I can't remember! Do lots of people experience this, and if so why?

Thank you.

It's not uncommon, although as violently as you describe. We know that body temperature tends to rise when an epidural is in place, and this is probably due to 'inappropriate' shivering like you describe. It is probably due to the cold epidural solution making the temperature of the spinal cord and brain fall, which tricks the body into thinking that it is cold. Warming the epidural drugs does have some protective effect.

[DavidBogod]

@Antidote

My question is just out of curiosity-

My epidural was topped up prior to having an emergency section, and I got really bad shivering and chattering teeth as if I was freezing cold. I think that the lovely anaesthetist told me it was normal, and may have explained why but I can't remember! Do lots of people experience this, and if so why?

Thank you.

That should be 'rarely as violently as you describe'

[DavidBogod]

@doricpatter

I have had both my babies in a very small CLU which does not offer epidurals to any labouring women and advises that women should plan to have their baby elsewhere if they want an epidural. It does say in their leaflet that women who change their mind could be transferred in labour (to a bigger hospital about an hour away).

I wondered if this is a common arrangement because a lot of other Mumsnetters were shocked when they heard that epidurals weren't ever available here. I also wondered if you know how common it is (in general terms - obviously you can't know about individual hospitals) for a woman to have to transfer in labour in order to receive one.

In the event my first was a section so I had a spinal anyway. I would like to state for the record that the anaesthetist who managed to successfully administer a spinal to someone as fat and oedematous as I was is a legend and should get a pay rise

doricpatter. It's only a small percentage of women who deliver in midwifery-led units without any epidural service, and of course, they are told in advance that they can't have an epidural unless they move to the big hospital down the road, so at least they know where they stand. Transfer rates vary, and those units which are located in the same building as the consultant-led service tend, unsurprisingly, to have transfer rates which are higher than isolated units. Figures vary from 10-30% of women transferred in labour, the higher figure tending to occur in those units which are open to first-time mothers (not all are). Of course, not all of these transfers are for pain relief.

[jmp6]

Dear Dr Bogod,

Can you easily tell the difference, in your experience between midwives that support womens requests for an epidural and midwives that don't?

[Nuttychicken]

I would love feedback about why mobile epidurals do not appear to be used in the UK (unless in private hospital settings) Is it due to cost implications? It seems rather strange to me when standard epidurals are seen to limit mobility and this limited mobility is often the cause of the perceived increased risk of complications with an epidural.

Could you explain the differences between a standard and mobile epidural please?

Thanks!

[DavidBogod]

@LeninGrad

I felt so utterly let down when having DS1 that it took so long for an anaesthetist to be available that fetal distress set in and I was rushed through for an emcs under ga.

I was aiming for a home waterbirth but had to go in for induction and then arm. Doing this without having someone free to give me an epidural was just appalling. Labour was fast and furious and it all spiralled out of control very quickly. And I did do all the prep, I just happened to not be able to cope with the pain of cxs at all. Same with second labour which started naturally but they were quicker to take me straight through for a CS so I could at least be awake.

In fact, I find it extraordinary that we haven't done more on all this as a society, we need walking epidurals and similar options.

Also, it's not just about epidurals on demand, CSs should be on demand too. I had to fight for one second time around after I was told that there was no guarantee of getting an epidural if I wanted one that time either. It's an utter disgrace.

Maternity services are woefully under-resourced. We need one midwife per mother, good birthing units and more support for home births. In any event we should not be restricting access to pain relief and CSs under any circumstances, it is inhumane.

My question(s) - why aren't walking epidurals offered commonly and what innovations are on the horizon for pain relief in labour and childbirth?

LeninGrad. There are quite a lot of misconceptions about mobile epidurals (as they have come to be known), so thanks for this question. In fact, pretty well every epidural performed in the UK now uses the dilute drug mixtures which are the key to maximising mobility. There are some fine 'tweaks' which can still be done, for example by minimising the concentration of local anaesthetic in the first epidural 'dose' and by using 'top-ups' delivered by the midwife (or, even better, by the woman herself) instead of a continuous infusion, or by using a combined spinal-epidural (CSE) approach. What really stops women mobilising is the rest of the childbirth package, including the near-ubiquitous use of continuous fetal monitoring, the drip and the reluctance of carers to let women out of bed (and, it must be said, the reluctance of many women in established labour to get out of bed!).

As for innovations, probably the biggest is the use of a very short-acting pethidine-like drug called remifentanil administered by the woman using an intravenous patient-controlled analgesia (PCA) system. It's not as effective as an epidural, but better than any of the other alternatives. There are still only a small number of hospitals offering this, however.

[emmaelf]

Good evening,

There is a direct link between epidural use and assisted delivery (forceps or ventouse). By advocating wider and wider use of epidurals, you are contributing to this birth statistic, with all the consequences of such a delivery on the physical and mental health of the mother and the baby. Do you think that resources would be better spent on providing one-to-one midwife care for all women in labour, thus enabling more of them (again according to research) to achieve normal birth?

[DavidBogod]

@jmp6

Dear Dr Bogod,

Can you easily tell the difference, in your experience between midwives that support womens requests for an epidural and midwives that don't?

They don't come with black hats on!

The best way is to ask a few searching questions when you first meet the midwife who'll be looking after you during childbirth. You can ask to change to a different midwife if the first is not sympathetic to your requests, but this is rather resource-dependent

[DavidBogod]

@MLWfirsttimemum

I had an epidural during the birth of my DD1 and as a result feel very positive about the entire birth experience, so to speak.

However, I had no dedicated midwife during the 10 hours leading up to having the epidural (despite having fetal monitoring) but as soon as the epidural was in I had to be monitored at all times by a midwife. This felt (to a layman) like the wrong use of resource.

My question is; is it actually absolutely necessary to be under dedicated observation by a qualified midwife when given an epidural or could a less qualified (or non-qualified person e.g. a husband)provide monitoring equally well?

MLWfirsttimemum. Interesting idea! At the moment, a permanent midwifery presence is necessary when an epidural is to be used, but I see no reason why a suitably-trained non-midwife could not provide the necessary extra care needed (I think I would draw the line at a well-meaning partner ). Off the top of my head, this could be someone at a nursing auxiliary level.

[DavidBogod]

@StarlightMcKenzie

Hi David,

Thank you so much for coming.

Could you tell me please anything about the effects of epidural anaesthsia on the birth hormone oxytocin and any implications this may have for the baby or mother post-birth.

Many thanks

StarlightMcKenzie. Oxytocin levels aren't affected by epidurals. Because of this, epidurals have no effect on the duration of the first stage of labour (although they may prolong the second stage, probably by an impact on the relaxation of the pelvic floor muscles). There is also no evidence at all that they interfere with breast milk production or the ability to breast feed, despite a widely-quoted but truly awful Australian study which suggested otherwise.

[DavidBogod]

@Nuttychicken

I would love feedback about why mobile epidurals do not appear to be used in the UK (unless in private hospital settings) Is it due to cost implications? It seems rather strange to me when standard epidurals are seen to limit mobility and this limited mobility is often the cause of the perceived increased risk of complications with an epidural.

Could you explain the differences between a standard and mobile epidural please?

Thanks!

By some miracle of technology, my post on this subject to LeninGrad appears just above (or below) yours. As I say, I don't think there are any of the old-fashioned 'standard' epidurals out there any more.

[Olivetti]

Hello
Thank you very much for coming on.
I had an epidural in November. My baby ended up being forceps delivery, due to her heartrate dropping after 2 hours pushing. However, I believe this was because my midwives mismangaged the pushing stage, byt failing to tell me when contractions came at least four times, so we lost valuable time. I was just one push away from delivering without intervention. Do you agree that this can be the case, and that it is not the epidural itself that necessarily increases the risk of intervention, but a failure to manage the situation? I want to have one next time, but intend to be much firmer about ensuring my contractions are tracked properly.